This article was downloaded by: [Queensland University of Technology]On: 20 November 2014, At: 18:01Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Total Quality ManagementPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/ctqm19

Total quality management: ahealthcare applicationLisbeth M. Claus aa Quality and Productivity Division, Maritz Inc. , 388 MarketStreet, Suite 970, San Francisco, SA, 94111, USAPublished online: 28 Jul 2006.

To cite this article: Lisbeth M. Claus (1991) Total quality management: a healthcareapplication, Total Quality Management, 2:2, 131-148, DOI: 10.1080/09544129100000015

To link to this article: http://dx.doi.org/10.1080/09544129100000015

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information(the “Content”) contained in the publications on our platform. However, Taylor& Francis, our agents, and our licensors make no representations or warrantieswhatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions andviews of the authors, and are not the views of or endorsed by Taylor & Francis. Theaccuracy of the Content should not be relied upon and should be independentlyverified with primary sources of information. Taylor and Francis shall not be liablefor any losses, actions, claims, proceedings, demands, costs, expenses, damages,and other liabilities whatsoever or howsoever caused arising directly or indirectly inconnection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden.Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

TOTAL QUALITY MANAGEMENT, VOL. 2, NO. 2,1991 131

Total quality management: a healthcare application

LISBETH M. CLAWS Quality and Productivity Division, Maritz Inc., 388 Market Street, Suite 970, San Francisco, S A 941 11 , U S A

Abstract The continuous improvement model is making its inroads healthcare. The essential elements of T Q M are discussed in light of the healthcare environment. A number of TQMI healthcare models are reviewed and an eclectic implementation model is developed. The model emphasizes 'change' steps which an organization needs to undertake as well as a detailed implementation roadmap for healthcare institutions. Implementation obstacles and success factors for T Q M implementation in healthcare are presented.

Managing continuous change

The challenge of organizations in the 1990s is one of managing continuous change. Organ- izations are meeting that challenge by creating learning organizations in which the focus is on sharing information, creating intelligence and nurturing innovation. The rapid pace of change that the world has known in the20thcentury is especially prevalent inmedicineand healthcare.

Since the beginning of this century, there have been dramatic changes in the mor- bidity and mortality profiles of populations. Sanitary and standard of living improve- ments, as well as technological and medical innovations, have been both the causes and the consequences of these rapid changes.

The way in which healthcare is being delivered, financed and held accountable has also been subject to change. This has forced healthcare providers, who operate in an extremely competitive market, to focus more of their attention on market share, cost containment and quality improvement.

The continuous improvement model which is being adopted by industry as the necessary model for survival, is making its inroads into the healthcare market as well (Batalden & Buchanan, 1989; Berwick, 1989; James, 1989; Sahney etal . , 1989; Marszalek- Gaucher & Coffey, 1990). The management of such a change for a healthcare organization is the subject of this article.

Total quality management: elements of a definition

In short,'total quality management (TQM) is concerned with the management of organizational change toward continuous improvement of the processes which govern the way work gets accomplished. While the definitions and applications of T Q M can vary

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

widely, based on which 'guru' one adheres to (Juran, 1964; Crosby, 1979; Feigenbaum, 1983, Deming, 1986; Imai, 1986) there seems to be a general consensus about the essential elements o fTQM (Scott, 1989).

First, T Q M is geared to the continuous improvement of quality in an organization. Generally, the goal of 'perfect' quality is unattainable because of the limitations inherent in people and technologies. Therefore, the attainment of quality is a never ending journey. Continuously improving work flow processes is a quest for quality in itself. In healthcare, this notion of an 'imperfect' world is well imbedded in the work of its professionals who are confronted with life and death challenges on a daily basis.

Secondly, T Q M is based on customer expectations, and on meeting and anticipating customer requirements. This, obviously, entails the proper identification of who the customers are (i.e. the internal and external customer in the customer chain), accurate knowledge of these expectations and developing action plans to close the existing gaps in meeting customer expectations.

Identification of the customer chain is a relatively new concept among healthcare providers. The patient is traditionally viewed as the ultimate 'external'customer. The idea of the existence of other external customers, such as the buyers or financiers of healthcare services, has only recently been acknowledged (Casurella, 1989). In addition, in an environment characterized by professional dominance, the identification of an internal customer chain (i.e. one department serving another) is rather alien.

Thirdly, T Q M requires an organization's long-term commitment. T Q M is most adequately described in terms of a 'process'. It is a process of many small incremental changes rather than a short-term drastic intervention. Hospitals and healthcare systems, not unlike other business enterprises, have tended to focus on immediate, short-term results. This short-term orientation is often reflected in their use of 'traditional' versus 'activity-based' cost management (Johnson & Kaplan, 1989). Several healthcare insti- tutions in the United States have begun their T Q M journey, and are eager to share their successes and lessons learned with others in healthcare. The commitment of time and resources toward the achievement of a long-term goal requires a shift in focus for many organizations. Only the belief that such a shift is necessary for the ultimate survival of the organization in the future will channel resources in the right direction.

Fourthly, TQM is management driven. The impetus, direction and vision originate at the top of the organization and are cascaded down through the various levels of the organization. By the same token, the behaviour which is consistent with the continuous improvement approach is exhibited by senior management and emulated by others in the organization. Applied to the hospital setting, with its dual line of authority (Coe, 1978), this means that both administrators and physicians will have to take the lead and move beyond 'advanced lip service' in applying the T Q M principles and tools to their worksetting.

Fifthly, the TQM process ultimately has to involve all employees to be successfully integrated. I t always requires that employees are 'empowered' to make continuous improvement changes within the scope oftheir daily tasks and responsibilities. The degree of empowerment will depend heavily upon the regulatory nature of the work done. Due to the professional autonomy of the different healthcare providers, the empowerment of employees will have to be limited to areas beyond the scope of professional licensing and expertise. In other words, there will always remain, within the work flow process, areas of specific expertise and responsibility reserved to the appropriate bealthcare professionals. If properly introduced and managed, empowerment occurs consistent with required/ assigned responsibility.

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

TQM: A HEALTHCARE APPLICATION 133

Sixthly, T Q M is focused on collaborative teamwork. The interdependence of tbe various tasks and the specialized knowledge required in the work flow process necessitate a collaborative team spirit to complete the right task right the first time--and all the time. Teamwork has been the modus operandi in modern healthcare. The familiarity of healtb- care providers with teamwork should make the T Q M process particularly well suited to their work environment. However, the emphasis on the personal responsibility of the physician can impede the true collaborative effort of interdisciplinary teams.

Seventhly, T Q M in its application aims at changing the attitudes as well as the behaviours of its work force. Continuous improvement is not only a philosophy, but also a way of life. Management and employees need to embrace this newly found passion for quality. Bringing about these transformations in people's attitudes and behaviour requires, however, different sets of techniques. While a change in attitude requires awareness that there is a better way and a commitment to that change, a change in behaviour necessitates the belief that the transformation can be done. Managing this type of change will present a particular challenge for the healthcare industry. However, with the emergence of different types of external customers, such as large employee groups, third party payers, etc., a new notion of accountability might ultimately be forced upon the healthcare industry.

Finally, T Q M is aimed at achieving a harmony between technology and people. In order to continuously improve their operations, companies will have to invest in the new technologies which will maximize the quality of the products, services and processes. They will also have to maximize the utilization of the discipline systems that they have in place (i.e. strategic planning, resource utilization, risk management, inventory control, etc.). However, effective utilization of these technologies will be insufficient, unless the human resource utilization is maximized. Ultimately, it is people who will utilize the systems in order to meet the requirements of the customers. T h e equilibrium between technology and people is personified in the ultimate quality of care that the patient receives and the customer is willing to pay for. Striking this balance in the management of a healthcare institution is an important element in obtaining the desired continuous improvement culture.

By virtue of the magnitude of change, the road to quality and continuous improve- ment is a long and arduous one. The cultural change required is not possible without drastically different processes of operations. T h e gurus stress that it can take several years to obtain results. It does not have to be that way if employees are permitted to share a common fate, are empowered to make incremental improvements, and are properly reinforced and rewarded for process and result improvements.

TQM models f o r hea l thcare organizat ions

The existing theoretical body of knowledge with regard to T Q M and continuous improve- ment processes has been shaped over the past decades by a variety of gurus. The appli- cation of the management philosophy to organizations is also widely available, and specific process improvement tools and techniques have emerged. As companies are looking to continuously improve the quality of their organization, they are attempting to validate the general T Q M principles and techniques within their own industry.

Existing TQMlhealthcare models

Healthcare institutions have caught onto the quality revolution sweeping corporate America. Healthcare organizations around the country are starting to adopt T Q M

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

134 L. M. CLAUS

principles and techniques. A number of operational models have been adapted from indus- try and applied to the healthcare setting. These models are usually presented as steps to quality or phases of quality improvement. As an illustration, five different models deserve attention. They are labelled by their institutional affiliation for simplicity purposes.

The N K C model. This model, developed by NKC Inc., the winner of the First Annual Healthcare Forum/Witt Award, describes the 10 steps to quality it took in the 'absence of a model' (Powers, 1988). Since then, more sophisticated models have been described in the healthcare literature. One needs, however, to keep in mind that this healthcare institution was one of the first to actually apply T Q M to the hospital setting and that Total Quality processes are still very new to healthcare.

The Hospital Corporarion of America Model. The Hospital Corporation of America has been using the Deming philosophy, and adapted the well-known 14 Deming points and a strategy called FOCUS-PDCA to the healthcare setting. Nackel & Collier (1989) described a five-step quality improvement implementation process. These steps are: organizing efforts to improve quality, action plan to improve quality, pilot implementation, executive visioning, and developing and implementing cultural change strategy.

The Harvard Community Health Plan Model. The model developed and professed by the HCHP describes four phases of quality improvement (start-up, test, scale-up, institutionalize) and 12 specific steps of the quality improvement process (Harvard Community Health Plan, 1989; Berwick et al., 1990). The model has been tested quite extensively through the various phases of the National Demonstration Projects.

The American Hospital Association Model. Brent C. James (1989) describes three major steps (prepare to improve, implement, innovate) for achieving high quality and appropriate cost reduction, and developed an operational model for quality in healthcare based on the four different dimensions of quality (quality of organization/management, quality of evaluation, quality of service, value of care).

The University of Michigan Medical Center Model. The University of Michigan Medical Center (UMMC) was a participant in the National Demonstration Project and winner of the Second Annual Healthcare Forum/Witt award. Their total quality process includes a number of phases (create awareness, top leadership training, development of internal resources, mid-level training, introduction of quality improvement teams, employee and clinical training) and is conceived as a 5-year process (from awareness to maturity). Marszalek-Gaucher & Coffey (1990) in their book Transforming Healthcare Organizations describe a specific total quality roadmap for UMMC.

Inreviewingthesemodels, an eclectic approach iswarranted. Namely, eachoneofthese models, although different in approach, contains necessary elements for the successful implementation of a T Q M process in the healthcare setting.

Rather than critically analysing these existing healthcare models and identifying potential gaps, a different method was used to build the T Q M model described hereafter. Using a technique known as affinity diagram/KJ Method (Brassard, 1989), the various steps/elements/components of the existing healthcare models and additional elements deemed important in the T Q M process (as defined by a team of T Q M implementation practitioners) were used to build a more comprehensive, yet eclectic, implementation model.

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

Figure 1. Model for chntlgr.

TQM: A HEALTHCARE APPLICATION

Phase V

Engaging the

An eclectic TQMIhealthcare model

Phase IV

FOCUS the

Models are ideal types by which an organization guides itself. Once developed, they are implemented, reviewed and modified. Keeping in mind that T Q M is a model of organizational change, a number of necessary conditions will need to be present in order for change to occur. If a hospital's continuous improvement philosophy is to be reflected in the attitude and behaviour of its employees, the hospital environment will need to become a learning organization and a number of 'change' steps need to be undertaken. These conditions for change are:

environment

(1) organizing for change; (2) preparing the environment; (3) empowering employees; (4) focusing the environment; (5) engaging the environment.

(see Fig. 1).

Phase Ill

Empower the

Organizingfor char~ge

environment

The cultural change required in a T Q M process is not possible without instituting drastically different processes in the organization. Organizing the change entails activities such as assessment, leadership, planning and goal-setting. Assessment requires an organization to identify its customers, analyse their requirements and the gaps in meeting these expectations. It also entails an initial bench-marking of the organization in terms of its competitors, as well as, an in-depth look at the relationship with its suppliers.

Leadership plays a crucial role in organizing for change. Besides the need to develop a passion for managing change, management will have to identify, and remove the existing barriers and obstacles for change, and determine the critical success factors in the management of the cultural change.

employees

Phase I1

Prepare the

Phase 1

Organising for

environment

change

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

136 L. M. CLAUS

Organizing for change also entails planning and goalsetting. This requires the devel- opment of a vision for the organization, identification of the values and development of the organization's mission. New goals and expectations need to be set as well as near-term objectives. Finally, an integration and deployment strategy needs to be developed.

Preparing the hospital environment

A hospital aiming at adopting the continuous improvement philosophy and internalizing this new organizational culture will face many changes in the way it operates, manages its people and responds to the customer. Therefore, there is a need to effectively prepare the environment for the change process. Preparing the hospital environment entails many different things, such as information sharing, transfer of knowledge and the creation of an awareness, and commitment to quality improvement and customer orientation. Ways to prepare the hospital environment are interactive communications between management and employees, and overall education and training. Effectively preparing the organization ultimately consists of energizing employees to embrace the continuous improvement process.

Empowering the employees

Quality improvement principles have to be converted into action in order to achieve the desired change. This requires that individuals and teams of employees are empowered with the ability to effect change which will result in continuous improvement. Besides the acquisition of a number of problem-solving skills and quality improvement techniques, empowerment also requires transformational leadership skills of management. Manage- ment must create the proper environment, stay involved, and maintain the responsibility of managing the process and the results while growing the organization.

Focusing the hospiral environment

As the change process is introduced it is advisable to start with bite-size changes and focus on these changes within the hospital which will either carry the most weight or are rela- tively easy to institutionalize. As adults learn primarily by doing, there should be an opportunity for them to practice, in a relatively non-threatening manner, the principles they have learned. By giving the workforce bite-size pieces to digest and apply, the process of assimilating TQM becomes less unsettling to the employees. Then, the commitment to total quality emerges from being a mere philosophy that employees hear, to a way of doing things together as a team.

Focusing the environment also entails the ability to track the improvement and an ongoing review of the process. In order to track the improvement organizations need to develop adequate indicators and engage in bench-marking.

The T Q M process is a dynamic one. I t is dynamic in its scope and objectives for cultural change. It is also dynamic in that the process is constantly evolving and changing, along with the organization and workforce.

Engaging the hospital environment

The linal condition for change requires that the change is institutionalized within the structure and the culture of the hospital organization. Since T Q M is an evolving process aimed at continuously satisfying and exceeding customer expectations, each activity or

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

TQM: A HEALTHCARE APPLICATION 137

work flow process in the organization needs to be evaluated in terms of doing the right things, doing things right the first time, and consistently over and over. This engages the entire organization, because everyone in the customer chain has a customer who needs to be satisfied.

The environment can be considered totally engaged when two conditions are met: these are staying power and achieved outcomes. Staying power is difficult to attain because it requires that the passion for quality and customer focus needs to be constantly main- tained. I t is generally recognized that total employee involvement is achieved through immediate constant, and consistent reinforcement, recognition and rewards. The out- comes of engaging the environment into continuous improvement are cultural change, eliminated waste, reduced cost, increased productivity and increased customer satisfac- tion. I t is generally accepted among T Q M followers that quality is tied to results and financial benefits. The relationship between quality improvement and these outcomes, although available from testimonials from pioneering companies in the quality move- ment, are mainly qualitative and anecdotal in nature. Academic research is needed to demonstrate the link between quality and productivity outcomes in a quantitative manner (Fig. 2).

A TQM implementation road map

A continuous improvement strategy needs to be carefully developed, implemented and time-phased in a manner that can be effectively managed for short- and long-term results. Developing an integrated and comprehensive system is critical and the sooner a process is in place, the sooner results will be realized. An organization needs, however, first to be aware of the existing barriers and obstacles which can jeopardize the implementation of the quality improvement (QI) process.

Implementation obstacles

Healthcare organizations are facing a number of obstacles in their desire to implement a TQM model. A number of these obstacles are faced by any company, independently of the industry. In addition, a number of obstacles are believed to be unique to the healthcare industry.

Implementation obstacles germane to any industry are:

the relatively long learning curve the search for the perfect plan the advanced lip service paid to TQM the fragmented effort as a result of a lack of vision the general resistance to change the opportunity cost involved the short-term orientation of many companies.

Obstacles specific to the implementation of T Q M in the healthcare setting deserve special attention.

First, the heavy reliance on the quality assurance (QA) mode is a potential implernen- tation obstacle. QA activities have been described (Berwick, 1989; Casurella, 1989) as being limited to 'inspection' rather than improvement, focused on what has been done (outcomes) rather than how things should be done, concerned with meeting requirements rather than expectations, focused on monitoring and surveillance instead of quality

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

TQM: A HEALTHCARE APPLICATION 139

improvement. While it seems to be fashionable among the TQM converts to snub the quality assurance mode, one should keep in mind that in healthcare as well as in industry, the inspection mode has been 'the' dominant thinking with regard to quality. Within the QA departments, one can find the most staunch champions as well as resistors to the new continuous improvement paradigm.

A second obstacle in the successful implementation of T Q M is believed to be the professional dominance of physicians in teamwork. Coupled with the emphasis on the personal responsibility of the physician, this could severely impede the true collabor- ative efforts of teams. By the same token, healthcare has a much greater tradition of interdisciplinary teams than most work places.

A third implementation obstacle lies in the possible professional resistance from the many professional groups that are being represented in healthcare. Very little support for the T Q M process has come yet from the major professional associations representing physicians, nurses, pharmacists and other therapists in guiding their professionals with regard to their contribution and involvement in the T Q M process.

Finally, the precarious budgetary situation facing many hospitals and health systems today (Berwick, 1988), is often not conducive to monopolize the necessary resources to implement a continuous improvement process. Coupled with the long-term nature of the endeavour and results, this can create an attitude of procrastination among decision makers.

A three-phased implementation process

Although no perfect T Q M design can be plugged into a healthcare organization and meet all the organization's objectives, there are some basic steps that can be discerned. The following blueprint is based on the necessary conditions for change described in themodel. The description assumes a healthcare organization with little or no activities in the area of TQM.

In order to be successful, a continuous improvement process has to be management driven. The quality vision is cascaded through the organization from the top down. The three-phased approach presented here directly flows from this premise (Fig. 3).

The first phase (executive education and action) aims at consolidating the executive commitment and generating a consensus of vision and values about the quality process.

The second phase (middle management/supervisory education and action) further cascades the quality vision (and the operational and management change plans) and builds commitment at the mid-management and supervisory levels. A commitment which is vital to the successful implementation of any all-employee involvement process.

Finally, in the third phase (all employee education and action) the quality vision and plans are further cascaded down to the entire employee group and commitment, as well as action, are generated at the individual and work group levels. Although these phases will be discussed successively, they are interrelated and overlap in the actual implementation process.

Phase I : Executive education and commitment

The first phase of the T Q M implementation process focuses on senior management and, in particular, the executive team. I t comprises three different processes: assessment, planning and an executive retreat (Fig. 4).

1. Assessment. Most hospitals have in place, beyond the traditional quality assurance process, a number of practices and standards to assure the quality of care. Any T Q M effort

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

140 L. M. CLAUS

Figure 3. TQM implementation pyramid

should build upon the achievements and, sometimes, the lessons learned from these activi- ties. Hence, a first step in developing and implementing a TQM process should be to conduct an assessment and audit of all management and employee activities in the areas of quality and productivity. The main purpose of the assessment is to identify customer service gaps. The assessment insures that the ensuing process is managed from data and information.

The objective of the assessment is to gather information related to strategic planning, management styles, existing quality measures and indicators, and customer requirements. Paramount to the assessment process is the identification of the organization's internal and external customers. their reauirements uis-a-uis the oreanization and an initial bench- - marking to ascertain the competitiveness of the organization. A variety of existing manage- ment tools can be adapted for this purpose. The outcomes of this assessment process are a more customer-oriented organization cognizant of the expectations and requirements of its customers, and an executive visioning which allows the leadership of theorganization to see the broader picture of continuous improvement.

2. Planning. Executive management is actively involved in the planning and design of the educational experience with regard to quality and continuous improvement. The highlights of the assessment results are assimilated and reviewed collectively by the execu- tive team in a group review process. It is not uncommon, at this time, for the executive team to want to redesign the process, or even get out of the process altogether. A major reason being that the executive team feels threatened and defensive about the results of the assessment. In successful processes, the Chief Executive Officer's (CEO's) response will

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

TQM: A HEALTHCARE APPLICATION

PROCESS FLOW

CONCEPTUAL VIEW (Objectives)

Assess - Strategic plan - Management style - Quality efforts - Customer

requirements

Assessment results - Customer orien-

tation - Customer re-

quirements - Executive

visioning

Highlight assess-

, , : design education for retreat 1 LOGICAL VIEW (Outcomes)

Approved retreat agenda and plan

Increase awareness Gain commitment Clarify goals and responsibilities for system implementation

Develop macro- performance measures

Agree on change management plan

Identify change agents/champions

Vision and values statement

Macro-performance measures

Cultural change

Operational change

Commitment plan

ACTUAL PROCESS (Custom-designed to fit oraanizational structure and needs)

Figure 4. Phore I : executive education and acrion

determine the future of the process. It is advised that the CEO reaffirms commitment and expects the executive team to get on board, while appropriate input, guidance and support is provided.

The visionary and charismatic style of such a CEO has been documented extensively, especially among the Baldridge and Deming award winners. It plays a crucial role in delivering the message that continuous quality improvement is the 'only' way to effectively manage change, and that a quality focus and customer orientation is the appropriate bchaviour for managers to exhibit and employees to emulate. The outcome of this planning process is an approved agenda and plan for the executive retreat.

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

142 L. M. CLAUS

3. Executive retreat The executive retreat, a two or three day meeting of the execu- tive team away from the daily pressures, activities and interruptions of the hospital, then becomes a 'landmark' event. The objectives of the retreat are ambitious and multiple:

increase awareness and gain commitment clarify the goals and responsibilities for the implementation of the continuous improvement process develop a consensus vision with regard to quality develop macro-measures of quality performance and agree on the plan to manage the change.

This retreat is best lead by an experienced executive facilitator who can appropriately guide the executive team in its genuine quest for quality. It is paramount that a number of deliverables come out of the executive retreat. These deliverables encapsulate the 'core' consensus of the healthcare organization with regard to quality and include specific plan measurements. These deliverables can be characterized as follows.

(I) A specific statement regarding the organization's vision and values about quality and the customer. As such, this often takes the form of a revised mission statement by which the entire healthcare organization will live.

(2) A set of macro-performance measures with regard to quality by which the perform- ance of the organization will be judged. While corporate performance is traditionally evaluated on the basis of cost and revenue objectives, a new dimension should be added which reflects management excellence in a number of key result areas, and indicates quality and continuous improvement gains. This measure, at the corporate level, is best kept simple and easy to comprehend.

(3) Three specificmanagement change plans are developed at the retreat. The first plan is a cultural change plan and deals with changes in people throughout the customer chain. I t emphasizes how employee concerns will be handled and how the people of the organization can gain ownership in the process. The second plan focuses on operational change and deals with changes in systems and technologies. The third plan is a personal commitment plan and outlines management's own commitment to the quality process.

Obviously, the executive retreat has ambitious goals. An organization accomplishing deliverable (1) could conceivably label its efforts successful. Ongoing maintenance of the process on a regularly scheduled basis would need to follow the executive retreat to ensure that deliverables (2) and (3) are accomplished.

Phase I I : Middle management/supervisory education and action

The second phaseoftheTQM implementation process isgeared at themiddlemanagement level of the healthcare organization. It is comprised of three specific processes (Fig. 5).

1. Awareness andcommitment. The outcomes and deliverables of the senior manage- ment phase are now further cascaded down to the management and supervisory levels of the organization through training and education. The quality vision and ensuing plans are translated into concrete action plans for and by middle management. T h e commitment at this level is of primary concern and extremely critical to the successful implementation of the T Q M process. This step is often overlooked or not handled adequately.

Middle management's reaction can often be characterized as: 'this is just another program, which will come and go as many others have in the past'. Overcoming the scepticism hurdle is not an easy task. T Q M is anew way of thinking which is contrary to the

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

TQM: A HEALTHCARE APPLICATION 143

PROCESS CONTROL F I + + I q FORCE EDUCATION

CONCEPTUAL VIEW (Objectives1

Increase awareness Gain commitment Orient to change Develop opera-

tional change

Identify c r i t i ca l success factors and obstacles

Refined operationa and cultural change

Cri t ical success factors and obstacles iden- t i f ied

Project management system

Commitment to new direction

Define micro-perfor- mance measure

Define monitoring strategies

LOGICAL VIEW (Outcomes)

Micro-performance measures

Feedback system

Gain understanding of TQM tools and techniques

Apply s k i l l s to a healthcare assign-

~ p p l y s k i l l s for improving team's effectiveness

Practical s k i l l s i n TQM s t a t i s t i c a l tools and tech- niques

Practical s k i l l appli cation project

ACTUAL PROCESS (Custom-designed to f i t organizational structure and needs)

Figure 5. Phore 11: middle rnanage~~anr/rupe~visory educorion and ocrion.

task-oriented approach dominating this level of the organization. The main objective of the awareness phase is to facilitate, with middle management, the critical success factors and obstacles in the implementation of a continuous improvement process. In a healthcare setting this is often done in separate groups for the physicians and nurses in order to identify specific issues to their profession and gain their initial buy-in. The process is then continued for the middle management group at large.

A similar strategy is used for union environments where a joint partnership will need to be developed between union and management to gain the union's involvement in the process.

The outcomes of this awareness process are to have gained management's commit- ment, visibility and active participation in the process, and to increase their understanding of how they can contribute to the process through their daily performance and behaviours.

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

144 L. M. CLAUS

2. Vertical task force education. As management's commitment to the continuous improvement process is gained, they meet in cross-functional task forces with the purpose of developing the second level quality measures for the healthcare organization. Using the broad macro-measures developed by the executive team, managers and supervisors are asked to develop specific quality performance indicators for their division. Then, in a group process review approach, they gain the approval for these measures from their colleagues in other divisions. In accordance with the customer chain concept, divisional measures do not stand alone, but have an impact on other divisions which are either clients or suppliers in the workflow process. As a result of this process, the organizationnow has a number of macro-QI measures (developed for the entire organization) and a set of meso- QI measured (developed at the department or division level). The micro-QI measures will be developed by idea project teams at the grassroot level of the organization. Once the measures are agreed upon, monitoring strategies need to be developed and a feedback system put into place. As the quality goals, plans and measures are being cascaded from the top of the organization down, they are internalized by the next layer of management and further expanded, refined and specified. This process enables cach level of management to add its own expertise and ownership to the process, and enable the healthcare organization to coordinate all existing and future performance improvement activities under one specific umbrella and vision.

3. Adwanced TQM training. The ultimate goal of an organization in implementing a continuous improvement process is to go beyond the internalization of the TQM prin- ciples among its employees and have employees behaving in ways which are consistent with high quality and low cost. Behavioural change among employees requires a percep- tion that the change is feasible and knowledge of the proper tools to make that change happen. Middle management and supervisors, because of their unique position in the organization, play a dual role in the behavioural change process. First, they are the conduit between senior management and the employee base. Secondly, they can beused as trainers to bring the necessary skills to the employee level. This, of course, requires that they become proficient in these skills themselves.

The objective of the advanced T Q M training for middle managers is to gain an understanding of the T Q M tools and techniques. A variety of these techniques, although originally developed for industry, have universal application. For example, problem- solving techniques, statistical process control, work flow process documentation, vari- ation, bench-marking, etc., can all be applied successfully in the healthcare arena. Once these basic and more advanced skills are acquired, they need to be applied by managers to specific healthcare applications in their work flow. As they have become familiar with the concepts and their applications, they can then apply these skills for improving the team effectiveness of their departments. In that way, training is phased inro the organization, as needed, with increasing sophistication.

Phase 111: All employee education and action

The third phase of the T Q M implementation process is geared at all employees. I t includes three distinct processes: awareness and commitment; quality education and training, quality action (Fig. 6).

1 . Awareness and commitment. Once commitment and quality process have been established at the management level, the vision and the change plans are further cascaded

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

PROCESS CONTROL

CONCEPTUAL VIEW (Objectives)

commit t o vision values

Orient t o quality process

Identify the customer chain

Gain understanding of problem- solving process

Commitment pledge Ident i f icat ion of

internal/external customers

Problem solving and methods

Gain understanding of TQM tools and techniques

Apply s k i l l s t o assignment

Develop personal action plan

LOGICAL VIEW (outcomes)

Practical s k i l l appli cation project

Personal action plan

Participate i n con- tinuous improve- ment team projects

Track quality indicators

Provide feedback of quality resu l t s

I n s t i t u t e a reward system

Continuous improve- ment of processes - increased qual i ty - reduced cost

Employee goals aligned with orga- nizational goals

ACTUAL PROCESS (Custom-designed t o f i t organizational s t ructure and needs)

Figure 6. Phase 111: all employer education nttd orrio,t.

down to the all-employee level. Theobjective at this level is to have the employees commit to the new vision and values, to familiarize them with the customer chain, and to orient them to the quality process. I t also entails employees having an operational understanding ofthe problem-solvingprocess so that changecan beeffected. Thcoutcomeofthisprocess is a commitment pledge from each employee, and their intrinsic belief that their performance and bchaviour is important to thc overall quality cause.

T h e awareness of and commitment to the hospital's quality vision is an ongoing interactive process between management and employees. Due to the nature of a continu- ous improvement process, the vision will emerge, evolve and mature and, therefore, will necessitate constant dialogue in the organization.

2. Quali ty educar~on and training. For employees to be 'empowered' to make changes for the betterment of theorganization, thcy need to have thenecessary tools and techniques.

Oncc employees have learned these tools, they require a structure to practice them. Under supervision, they are given the opportunity to apply thesc newly learned skills to an

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

146 L. M. CLAUS

application assignment. Using the problem-solving method, teams of employees brain- storm critical quality issues and, guided by their management, select a particular work flow process for case study review. This gives them a chance to apply the T Q M techniques in a learning environment. In addition, they develop their personal action plan in supporting the T Q M process of the organization.

The outcome of this process is twofold: a practical skill application project and a personal action plan.

3. Quality action. Employees are now ready to apply what they have learned and begin affecting the organization in a positive manner. During this process, employees participate in a variety of continuous improvement projects from special quality task forces to proposal systems and natural workgroup activities. The range of activities is broad and unlimited.

At the same time, the QIs (macro-, meso- as well as micro-) are now fully in place and tracked on a regular basis throughout the healthcare organization. T o insure the stay- ing power, organizations have relied successfully on reinforcement, recognition and performance-based rewards. Other elements of staying power are ongoing education and training, total employee involvement (including the family unit), and consistent manage- ment participation and visibility in the process. The quality improvement results are communicated and evaluated on a regular basis throughout the entire organization. The long-term outcome should be a measurable improvement in quality and reduced costs as the individual goals of the employees are aligned with the organization goals.

Summary and benefits of this approach

Reflecting upon the T Q M model and implementation blueprint, the ultimate question becomes why should a hospital be concerned with rethinking the operational principles of its organization. Although there has always been a tendency 'not to fix things which were operating smoothly', recent thinking in management indicates that this premise is no longer valid. In a rapidly changing and competitive business environment, as is the case in the healthcare industry, a new kind of management style is emerging. I t is based on the belief that the management practices which made healthcare institutions successful in the past might not necessarily make them successful in the future. It is also grounded in the belief that with the emergence of a variety of 'new' customers (i.e. the payers of the healthcare services) more attention will need to be paid in satisfying the needs of multiple customers with divergent requirements and expectations.

The list of elements which contribute to the success of a continuous improvement process is long and often vague. It includes key buzz words such as teams, education, training projects, ideas, feedback, reward, recognition, empowerment, communication, employee involvement, staying power, evaluation, measurement, valuation, etc.

This list can be reduced to a number of key processes (Fig. 7).

(1) Assessment Where is the organization at now? Where does it want to be in 1 year, 5 years or even 10 years from now with regard to meetinglexceeding the expectations of its customers while remaining a viable business enterprise.

( 2 ) Measurement Measurement allows anorganization to translatecorporate objectives into identifiable measurable and attainable quality performance goals for all employees.

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

TQM: A HEALTHCARE APPLICATION 147

Figure 7. Cririrol implententotion elements.

( 3 ) Ongoing employee education This is a broad term to cover all education and training activities which will inform, educate and empower employees so that they have the necessary knowledge, commit- ment and participation in the continuous improvement process.

( 4 ) Communications and feedback Interactive communication vehicles arc necessary to develop awareness and commit- ment to the quality process. Employee involvement can be gained through input and feedback.

( 5 ) System information and cracking Ongoing analysis and management information is necessary to document and support the quality improvement results. Feedback provides the performance link between objectives and results.

(6) Recognition/reward The need for positive reinforcement for specific behaviour is well recognized in successfully effecting behavioural change. Since the continuous improvement pro- cess is of a long-tcrm nature, small incremental changes need to be constantly rein- forced. Rewards should be equally balanced between achieving actual measurable results and taking the process steps necessary to achieve these results. Reward and reinforcement can also enhance the staying power once the process has been implemented.

The rationales for engaging in a TQM effort are diverse. A total quality rationale can range from the very visionary (ideological reasons for embracing the philosophy) to the very rational (what will it eventually mean for the bottom line). In between, there are hybrid reasons for implementing such a process which range from not wanting to be left out on an

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014

148 L. M. CLAUS

innovation, to capitalizingon the marketability of the process. Even within a same organiz- ations, various internal customers might have divcrgent reasons for promoting (or resist- ing) the implementation of a continuous improvement process. Whatever the intentions are, the ultimate result of the continuous improvement process is meeting customers' expectations at a lower cost. Two essential elements of survival in current business practices.

References

BATALDEN, P B. & H~'CHANAS, E D . 1989) InJusrrlal m.,rlcl,ut qurllry Improvemenl, ~n N. G o r o n e ~ o & D.H. NASII (Eds) Pruitdtrtf C)tzo!in, C d r c 'I'h.. Chlrllc.rrpr r t> Clt,,,rt~,tr (Philndclphra. PA, Amerlcm College of ~- ~ . Physicians), pp. 133-154.

BERWICK, D.M. (1988) lndurtriol Qunliry Control and American Health Care Quo1it.v: Early Reports on o Dsmonsrrarion Projrcr (Chicago, IL, Paper presenred at the 1988 Juran Institute Conference).

BERWICK, D.M. (1989) Sounding board: Continuous improvement as an ideal in healthcare, New England JofoumnlofMedicinr, I , pp. 53-56.

BERWICK, D.M., GODFREY, A.B. & ROESSNER, J. (1990) Curing Hdolrh Core (San Francisco, CA, Josrey Bass). CA~URELLA, J. (1989) Managing a 'roral qualiry' program, Federation ofAmerican Heolrh Syrremr Rmtew, July!

August, pp. 31-33. COE, R.M. (1978) Sociology $Medicine (New York, McGraw-Hill Book Company). Cnoseu, P.B. (1979) Quoliry is Free. Tha Art qf Making Qualiry Certain (New York, McGraw-Hill Book

Company). DEMING, W.E. (1986) Our ofrhe Crisis (Cambridge, MA, MIT Centre for Advanced Engineering Study). FEIGENBAUM, A.V. (1983) Total Quality Control (New Yark, McGraw-Hill Book Company). H A R V A ~ COMMUNITY HEALTH PLAN (1989) Improwing Health Care Quoliry. A Comprehenriue Currirulumfor

Henlrh Core Execuriuer, Managers and Clinicion Lenderr (1989), (Brookline, MA, Harvard Community Health Plan).

IMAI, M. (1986) Kaizen (New York, Random House). JAMES, B.C. (1989) Quolily Monagemenlfor Henlth Core Deliwry (Chicago, IL, The Hospital Research and

Educational Trust of the American Hospital Association). JOHNSON, H.T. & KAPLAN, R.S. (1989) Relenan~e Lost, The RirenndFallqfManagem~nt Accounting (Cambridge,

MA, Harvard Business School Press). JURAN, J.M. (1964) Mot8agerioI Breakthrough (New York, McGraw-Hill Book Company). MARSZNEK-GAUCHER, E. & COFFEY, R.J. (1990) Transforming Healthrore Orpnizorionr (San Francisco, CA,

IaKey-Bass Ltd). NACKEL, J.G. & COLLIER, T.A. (1989) Implementing a quality improvement program,Journol ofthe Society of

Heolrh Syrtemr, I, pp. 85-99. OBERLE, J. (1990) Quality gurus, the men and their message, Tmitting, I, pp. 47-52. POWERS, M.B. (1988) Quality takes 10 steps forward, Healthcare ForumJournal, 31,5, pp. 29-34. SAHNEY, V.K., DUTKEWYCH, 1.1. & SCHRAMM, W.R. (1989) Quality improvement process: The foundation for

excellence in healthcare,lfournolofrhe Socieryfor Health Syrremr, I, pp. 17-28. SCOTT, W.B. (1989) TQM expected to boost productivity, ensure survival of US industry, Aoiorion Werk &

Spore Technology, 4, pp. 64-69.

Dow

nloa

ded

by [

Que

ensl

and

Uni

vers

ity o

f T

echn

olog

y] a

t 18:

01 2

0 N

ovem

ber

2014